SOAP Word- Sexually Transmitted Illness
Identify :
United States College
Frequent Sickness Throughout the Lifespan -Scientific Practicum: FNP592
Teacher:
Date:
SOAP Word- Sexually Transmitted Illness
SUBJECTIVE DATA:
ID: A.A is 39-year-old Hispanic Feminine DOB 03/15/1982. she got here to the clinic because of ache and burning sensation that has been happening for the previous 10 days. She is a dependable supply of knowledge.
Chief Complain “I’ve been experiencing ache and a burning sensation when urinating. I’ve additionally been experiencing a vaginal discharge that has persevered for the previous ten days.”
Historical past of current sickness: Mrs. Jane Anderson, a 39 years previous feminine, presents to the clinic with complaints of ache in her decrease stomach and a burning sensation every time she pees. She verbalizes that the situation started about 4 days. She additionally added that she had been experiencing urinary urgency and an elevated urinary frequency previously three days. She has been visiting the toiletries round ten occasions a day. The affected person additionally reported that she has been experiencing a brown vaginal discharge for the previous week, and her urine has been having a cool odor after she had unprotected intercourse together with her earlier boyfriend. The affected person indicated that the urinary frequency and the foul odor distorted her work routine, messing up her focus on the workplace the place she works as an accountant. Therefore, she tried utilizing some ache killers to relent the ache, however they had been unfruitful. This made her search medical consideration. In line with her suggestion, the ache worsens every time she urates, and the ache is neither sharp nor boring. She outlined the ache to be on a scale of eight/10 and reported no assuaging or relieving elements to the ache. She admitted to being sexually lively however with a couple of accomplice since her husband died. The affected person stated that her menstrual cycle can also be common, and he or she skilled it like every week in the past and refuted ache throughout intercourse. She added that she doesn’t have a fever, constipation, nausea, diarrhea, or vaginal bleeding.
Previous medical historical past: The affected person advised that she has been bothered by sexually transmitted illnesses like gonorrhoea and chlamydia. She additionally reported that in her younger life, she was bothered by an asthmatic situation.
Surgical: The affected person reported that she had undergone surgical procedures in each her younger life and maturity. In her younger life, she underwent minor surgical procedure for tooth extraction, whereas in maturity, she underwent a caesarean part whereas delivering her daughter.
LMP: Affected person final menstrual interval was 10/28/21.
Medicines: The affected person has been utilizing Advil OTC PRN to manage her ache.
Allergy symptoms: The affected person reported that she has not been allergic to meals, medicines, nor the atmosphere in maturity, however she was allergic to mud and adjustments within the atmosphere at a younger age.
Immunization: The affected person reported that she is updated together with her immunizations, and he or she final obtained her flu and covid 19 jabs in April.
Household Historical past: The affected person reported that her paternal grandfather is alive and wholesome aged 90 years. Her paternal grandmother deceased on the age of 84 because of previous age-related comorbidities, and he or she was topic to diabetes and Alzheimer’s. She reported that each her maternal grandparents are deceased, however they had been all wholesome. The affected person additionally verbalized that her daughter is wholesome.
Social Historical past: The affected person is a window for her husband died 5 years in the past and he or she has not remarried. She lives together with her daughter of their rental condo. She is sexually lively however completely different individuals; therefore she makes use of safety however not at all times. She verbalized that she is an accountant at native finance and funding agency. She advised that she sometimes drinks three beers, however she doesn’t use leisure medication. She advised that she is a Christian and attends plenty Sunday morning collectively together with her daughter.
Evaluate of System:
Basic: The affected person denies latest adjustments in weight, fatigue, nausea, evening sweats, chills, or generalized weak point.
HEENT: Head; the affected person complained of no complications. Eyes; she wears glasses because of mild, and he does an eye fixed examination each 4 months. She is destructive for glaucoma, diplopodia, floaters, extreme tearing, or photophobia. Ears; she is destructive for ear microbes, tinnitus, or oozes from the ears. Nostril; her nasal mucosa is pink and destructive for any rhinorrhoea. Her olfactory delight is alive, and he or she is destructive for epistaxis. She additionally has no nasal polyps or any latest sinus infections. Throat and Mouth; she denied gingivitis, gum bleedings, nor any dental deformities. She additionally reported no hardships chewing or swallowing and sees a dentist after each 4 months.
Pores and skin: The affected person refuted wounds, rashes, bruises, bleeding, lesions, or pores and skin decolouration.
Respiratory: The affected person refutes coughs, wheezing, or laboured respiration. She additionally means that she is destructive for seasonal allergy symptoms.
Cardiovascular: The affected person refutes chest ache, edema, racing coronary heart, or orthopnoea.
Gastrointestinal: The affected person reported elevated decrease belly ache within the hypogastric area. She denies constipation, nausea, vomiting, diarrhoea, nor alterations in urge for food.
Genitourinary/ Gynaecological: The affected person reported a burning sensation upon urination, in addition to urinary frequency. She advised that she makes use of condom as a type of contraceptive and sexually transmitted illnesses (STD) management upon coital conferences although not at all times. She is constructive for various sexual companions. She is constructive for brownish vaginal discharge after copulation.
Musculoskeletal: The affected person refuted joint stiffness, again ache, or dislocations.
Neurologic: The affected person stories no seizures, paralyzes, syncope, or adjustments in reminiscence.
Lymph/Hematology: The affected person refuted elevated thirst or starvation, irregular temperatures, nor swollen glands.
Psychiatric: The affected person reported no melancholy, sleeping challenges, anxiousness, or temper disorientation.
OBJECTIVE DATA
Bodily Examination
Important Indicators: Temp- 98.9, Pulse- 75, Resp-18, O2- 98% RA, BP- 122/80, weight-150 lb., height- 5’.6”, BMI-24.2.
Basic Look: The affected person mirrored a well-nourished grownup feminine who was beneath no misery. She was well-groomed, alert, and oriented X four. Her response to queries was straight and logical.
HEENT: Eyes; PERRLA and EOMS intact. Eyes are additionally conjunctiva clear. Ears; TMs gray/pearly. Nostril; pink nasal mucosa, typical turbinates. Neck: Carotids no bruit or jvd. Mouth and Throat; pink and moist oral mucosa with a transparent oropharynx.
Pores and skin: The affected person’s pores and skin was clear, dry, intact, and regular shade mirrored her ethnicity.
Cardiovascular: Her S1 and S2 are common with a standard charge and rhythm. Her heartbeat has no murmurs.
Respiratory: Her chest partitions are symmetric, and her respiration is straightforward and common. The lungs are clear to auscultation bilaterally.
Gastrointestinal: The affected person’s stomach is flat, mushy, non-tender, and non-distended. She has tremendous lively bowel sounds in her 4 quadrants. Upon palpation, there was tenderness in her hypogastric area.
Genitourinary: The affected person’s bladder is non distended. Nevertheless, suprapubic tenderness was famous and a few irritations on the labia majora, minora, and vaginal space. There have been no ulcerated lesions famous. The lymph nodes had been impalpable. The vagina was pink in shade however had a cool odor with vaginal discharge famous. Her bimanual examination mirrored a friable cervix and constructive for CMT. Her uterus was of normal measurement and form.
Musculoskeletal: The affected person was in a full vary of movement in all her extremities.
Neurological: The affected person’s speech was clear and logical, with a very good tone. Her gait was regular, with a secure steadiness and an erect posture.
Psychiatric: The affected person was alert and oriented, sustaining eye contact when in conversations. She was appropriately dressed for the event and responded to queries.
Lab Assessments
– Urinalysis- It’s vital because it helps define kidney infections and displays potentialities of different comorbidities equivalent to diabetes, liver illnesses, or kidney illnesses.
– A urine tradition take a look at can be vital to attest to urinary tract infections (UTI) and establish micro organism or yeasts which might be triggering the infections.
– A dipstick urinalysis take a look at was additionally completed for infections the place the affected person was constructive for nitrates and leukocyte esterase.
– Vaginal discharge culture- Gram destructive diplococci, Neisseria gonorrhoeae, sensitivities
report pending. Optimistic monoclonal AB for Chlamydia.
– A Pap smear- A pap smear would even be vital since it could attest for the decrease belly ache. The take a look at was destructive.
– STD checks for gonorrhoea, syphilis, HEP B and C, HIV and chlamydia had been ordered.
ASSESSMENT
Differential Diagnoses
Chlamydia ICD-10-CM-A56.eight Chlamydia situation is an STD triggered by the chlamydia trachomatis micro organism (Witkin et al., 2017). On the preliminary levels of the situation, the situation doesn’t replicate particular signs since they manifest within the superior levels of the situation. Unprotected intercourse is among the many main methodology of passing the illness, although it doesn’t essentially contract via penetration (Witkin et al., 2017). The indicators that manifest in Mrs. Anderson replicate extra of the chlamydia. The situation is intently correlated to having a number of intercourse companions, earlier historical past of the situation, unprotected intercourse, and different sexually transmitted illnesses. The affected person advised having dysuria and decrease belly ache, that are among the many situation’s main signs. The monoclonal AB take a look at was constructive, confirming the chlamydia.
Acute vaginitis ICD-10-CM- N76.zero Vaginitis refers or numerous issues which will end in irritation or vaginal infections. The infections could also be attributable to a number of organisms like yeast or irritations from chemical compounds or sprays. The situation is described because the irritation of the exterior feminine genital (Vulva and the Vagina) (Mann et al., 2019). The situation might also end result from organisms handed between sexual companions. The situation manifests in slight foul-smelling urine, irregular menses with heavy circulation, burning sensation, itching, and the indicators worsen with intercourse (Mann et al., 2019). The differential can be disregarded for the reason that affected person doesn’t describe ache at intercourse.
Gonorrhoea ICD-10-CM-A54.9 Gonorrhoea is an STD triggered by the Neisseria gonorrhoeae. It primarily impacts the nice and cozy and moist areas of the physique, together with the urethra, the eyes, throat, vagina, and anus (Kirkcaldy et al., 2019). The vagina and the anus are probably the most affected areas by the dysfunction. The situation will be handed from one particular person to the opposite via oral, vaginal, and even anal intercourse whether it is practices unsafe. The signs of the situation differ in men and women. The situation in females manifests via vaginal discharge, ache or burning sensation whereas urinating, sore throats, agony within the decrease belly space, fever, heavy menses, and ache at copulation (Kirkcaldy et al., 2019). The prognosis could also be disregarded for the reason that patent didn’t have a previous historical past of the situation, nor did she have sore throats.
TREATMENT PLAN AND EDUCATION
I’d prescribe the affected person azithromycin 1g orally as a single dose or doxycycline 100mg twice a day. These dosages ought to persist for the following seven to 14 days (Phillips et al., 2019). The Meals and Drug Administration approves the drug azithromycin as the simplest antibiotic within the remedy of genital chlamydial (Phillips et al., 2019). The dug bars bacterial situations from multiplying; therefore, it’s among the many handiest medication in regulating the situation. I’d educate the affected person to steadiness her sexual life by practising secure intercourse with at the very least one accomplice. The affected person also needs to be counselled to guard herself utilizing efficient contraceptives equivalent to latex condoms. I can even educate the affected person to abstain from sexual exercise till she and her companions have accomplished the prescribed treatment.
Comply with up
It is necessary that you just preserve your follow-up appointment together with your supplier in three months. affected person must take all her prescribed antibiotics.
References
Kirkcaldy, R. D., Weston, E., Segurado, A. C., & Hughes, G. (2019). Epidemiology of gonorrhoea: A worldwide perspective. Sexual Well being, 16(5), 401. https://doi.org/10.1071/sh19061
Mann, A., Mehta, S., & Grover, A. (2019). Acute vaginitis: A uncommon reason for labial adhesions. JOURNAL OF CLINICAL AND DIAGNOSTIC RESEARCH. https://doi.org/10.7860/jcdr/2019/42259.13271
Phillips, S., Quigley, B. L., Aziz, A., Bergen, W., Sales space, R., Pyne, M., & Timms, P. (2019). Antibiotic remedy of chlamydia-induced cystitis within the koala is linked to expression of key inflammatory genes in reactive oxygen pathways. PLOS ONE, 14(eight), e0221109. https://doi.org/10.1371/journal.pone.0221109
Witkin, S. S., Minis, E., Athanasiou, A., Leizer, J., & Linhares, I. M. (2017). Chlamydia trachomatis: The persistent pathogen. Scientific and Vaccine Immunology, 24(10). https://doi.org/10.1128/cvi.00203-17
